University of Oslo
The Faculty of Medicine Institute of Health and Society
Department of General Practice and Community Medicine
Child birth in rural India
From home births to incentive-based institutional deliveries
A qualitative study on experiences and perspectives in Uttar Pradesh
By Marianne Gjellestad
Supervisor: Babill Stray-Pedersen, Professor I, Dr.med.
Co-Supervisor: Ane Haaland, Lecturer and Communication adviser
Thesis submitted as a part of the Master of Philosophy Degree in International Community Health May, 2010
II
University of Oslo
The Faculty of Medicine Institute of Health and Society
Department of General Practice and Community Medicine
Child birth in rural India:
From home births to incentive-based institutional deliveries A qualitative study on experiences and perspectives in Uttar Pradesh
Thesis submitted as a part of the Master of Philosophy Degree in International Community Health
By Marianne Gjellestad
Supervisor: Babill Stray-Pedersen, Professor I, Dr. Med
Co-Supervisor: Ane Haaland, Lecturer and Communication adviser
All photos by the author, taken with permission.
May 2010
III
Acknowledgements
This project would not be possible without the help and assistance from Reidun Refsdal and her staff at the Methodist Public Health Center in Mursan. I give her all my thanks; she and her employees were of vital importance for my fieldwork. In addition to the Director R. Refsdal herself, I would like to give special thanks to Dr. Mamta Kaushal, Dr.Vishal Michael and the nurses Roshni Ahmed, Lissy Abraham and Sandia Shibu for assisting me with different tasks.
The next thanks go to all the informants, both the Indian women who opened their homes for me and the officials who opened their offices. Their contributions are the basis for this paper.
My supervisors Prof. Babill Stray-Pedersen and Ane Haaland each gave me excellent supervision and assistance for this work. I am very pleased and grateful for their help. My thanks also go to Letten Foundation for the economic support that made the fieldwork in India a possibility.
Several persons have been consulted or involved in phases of this project. I would like to thank Dr.
Bernadette Kumar, Dr. Atle Fretheim, Manmeet Kaur, Marina de Paoli and Dr. Jagrati Jani for contributing their knowledge and advice. From the months in India I owe thanks to a group of people for helping me along the way: Dr. Tomas Alme, Dr. Chris Hena, Dr. Naresh Goel, Dr. Tsering Wangchuk, Amalie Nilsen and her fellow nursing students from Betanien Bergen, Trude Thommesen and the group of midwives in Hyderabad.
My family and my friends have given me inestimable support through the time of this study, and I thank them all for being in my life. For special contributions to the project I would like to thank HRH Crown Princess Mette-Marit, Cecilie (Titti) Kjølleberg, Marit Wahlstedt, Linda Tånevik, my parents Agnes and Tor-Axel Gjellestad and my cousin Lise Gjellestad who all participated in different ways with support and facilitation. I also send profound thanks to Michael Whitaker for reading my text and for being my white knight in Delhi.
I thank my classmates at the University for inspiration, support and fellowship through the last two years; I wish you all the best for your further work.
I am thankful for the strength that makes it possible to learn from our experiences, and for this great opportunity that has given India a place in my heart forever.
Finally, this work is dedicated to the mothers in Mursan, and to all women who give child birth in poor conditions.
Oslo, May 2010 Marianne Gjellestad
IV
Table of content
Acknowledgements ... III Abstract ... VII Prologue ... VIII List of abbreviations ... IX
1.0 Introduction ... 1
1.1 Background ... 3
1.1.1 Demographic profile ... 3
1.1.2 Maternal mortality in India ... 4
1.1.3. The National Rural Health Mission ... 7
1.1.4. The Norway India Partnership Initiative ... 8
2.0 Literature Review ... 10
2.1 Literature search ... 10
2.2 Current knowledge ... 10
2.3 Identified gaps in the knowledge ... 12
3.0 Study rationale ... 13
3.1 Research questions ... 13
3.1.1 Interviews with women who had recently given child birth ... 13
3.1.2 Interviews with health officials ... 14
3.1.3 Perspectives from the Asia Pacific Midwives’ Conference ... 14
3.2 Limitations ... 15
4.0 Methodology and research design ... 16
4.1. Theoretical framework ... 16
4.2 Study site ... 18
4.3 Study population ... 19
4.3.1 Women who had recently given birth ... 19
4.3.2 Health officials ... 19
4.3.3 The Asia Pacific Midwives’ Conference ... 20
4.4 Sampling ... 20
4.5 Timeframe ... 22
4.6 Data collection strategies ... 22
4.6.1 Observation and informal conversations... 22
4.6.2 Semi-structured interviews ... 23
V
4.6.3 Other sources of data... 24
4.7 Research assistants ... 24
4.7.1 Translator ... 24
4.7.2 The need for a male assistant ... 26
4.8 Reflexivity ... 27
4.8.1 My role as researcher and nurse-midwife ... 28
4.8.2 Staying at the Methodist Public Health Center ... 29
4.9 Data analysis ... 31
4.9.1 Management of data ... 31
4.9.2 Transcription ... 31
4.9.3 Steps of analysis ... 32
4.10 Discussion of methodology ... 32
4.10.1 Validity ... 32
4.10.2 Change of focus: Planning and implementation ... 33
4.10.3 Strengths and limitations summary ... 35
4.11 Dissemination of findings ... 36
5.0 Ethical considerations ... 37
5.1 Approvals and permissions ... 37
5.1.1 Ethical clearance ... 37
5.1.2 Other permissions ... 37
5.2 The Informed Consent ... 38
5.3 Confidentiality ... 38
5.4 To work with a vulnerable group ... 39
5.4.1 Meeting with the women... 39
5.4.2 Handling identified injustice ... 40
5.5 Beneficence and usefulness ... 41
6.0 Findings ... 42
6.1 Interviews with women ... 42
6.1.1 Family structure and function ... 43
6.1.2 Determination factors ... 45
6.1.3 Infrastructure and transport ... 48
6.1.4 Experiences in the institutions ... 49
6.1.5 Financial matters: incentives and expenses ... 52
VI
6.1.6 The gender of the new baby ... 54
6.1.7 Perception and thoughts on hospital and home delivery ... 54
6.2 Interviews with health officials ... 57
6.2.1 Intentions and implementation of the JSY/NRHM ... 58
6.2.2 Positive indicators ... 60
6.2.3 Challenges ... 61
6.3 Perspectives from the Asia Pacific Midwife Conference ... 63
6.3.1 Targets and visions ... 64
6.3.2 Subject development and academic progress ... 66
6.3.3 Collaboration and funding ... 67
7.0 Discussion of findings ... 69
7.1 Utilization of the services and the role of the ASHA ... 69
7.2 Unspecified satisfaction ... 75
7.3 Changing view on child delivery: from natural to medical happening ... 79
7.4. Financial matters: Incentives and expenses ... 83
7.5. Change of the family structure ... 86
7.6. Empowerment of women ... 87
8.0 Possibilities for future studies ... 89
9.0 Summary ... 92
Reference List ... 94
Epilogue ... 98
Appendix 1: Question guide for interviews with mothers ... 99
Appendix 2: Question guide for interviews with health officials ... 100
Appendix 3: Informed consent form ... 101
Appendix 4: Approval Ethical Committee in Norway (REK) ... 103
Appendix 5: Approval Ethical Committee in India ... 105
Appendix 6: Permission from Chief Medical Officer, Hathras ... 106
VII
Abstract
Title: Child birth in rural India: From home births to incentive-based institutional deliveries. A qualitative study on experiences and perspectives in Uttar Pradesh.
Supervisor: Babill Stray-Pedersen, Professor I, Dr.med.
Co- Supervisor: Ane Haaland
Researcher/master student: Marianne Gjellestad Introduction
India contributes to 22% of the global burden of maternal mortality. With the recent implementation of Janani Suraksha Yojana (JSY), a governmental program giving incentives for institutional deliveries, the National Rural Health Mission (NRHM) has made an extensive change in the maternal practices.
The target is to make at least 80% of the women deliver in hospitals and thus reduce the Maternal Mortality Ratio (MMR).
Objectives
The study aimed to increase the knowledge on the different perspectives after the recent change from home births to incentive-based institutional deliveries in the Hathras District, U.P., India. The main focus of my investigation was to enlighten the perspective of the women, and to see their experiences in relation to the perspective of health officials and midwives. Research questions comprised request about which parts of the NRHM/JST were utilized and why, and how this would affect the situation.
Methodology and research design
Data was collected through semi-structured interviews from two different informant groups: 22 women who had recently delivered in a governmental institution and five health officials working on different levels in the NRHM. A third perspective was gained through the researcher’s participation at an Indian midwife conference.
Findings/conclusions
The women in the Hathras District were overall satisfied with the experiences in the maternity institutions, even though a clear gap was identified between theory and practice in most of the investigated fields. Utilization of the services was highly associated with the work of the Accredited Social Health Activist (ASHA), but the mother-in-law seemed to be the main decision maker.
Determination factors for delivering their babies in institutions were desire for medical safety and assistance, poor hygiene or lack of assistance in the homes and instructions from community leaders.
The financial incentives were not mentioned as a reason for going to the facilities. The women’s experiences in the institution revealed several questions around the quality of care, most urgent the frequent use of Oxytocin. Also the unofficial payments in the facilities represent a challenge. The movement toward institutional deliveries was found to have a possible influence on the women’s relation to the health care system and on their way of viewing child birth as a natural versus a medical event. It was also found to possibly influence the family structure and contribute to empowerment of women.
Recommendations
Findings from this study suggest the importance of measuring what happens in the gap between intentions and implementations of NRHM and JSY, and the importance of investigating possibilities for improvements at this stage. Both quantitative and extended qualitative research is needed on the users’ experiences. Research on health professionals’ skills and attitudes will also be of importance for planning the future steps of the programs and understanding the mechanisms regarding sustainability.
Finally, awareness and research on how to increase the empowerment of women should be encouraged.
VIII
Prologue
In the evening, when it just has become dark, I hear a noise outside. I see lighted lamps and people gathering out in the courtyard and hear excited voices. When I come out I see a young girl lying on what I first recognize as the back of a truck, but when I give it another look I see that it is a cart behind a mule. The girl is lying still, looking pale and exhausted, with her legs spread and uncovered. Between them lies a newborn baby.
The talking calms when the nurses come out of the house. The baby stretches her naked body, the skin reflecting the yellow light of the lamps. Around the cart stands a group of women in long colorful draperies. For a second the world is quiet.
It all happens at the same time. The mother gets up from the cart and gets ready to walk into the clinic. Someone flashes a light to take a photo of the beautiful sight. The mule gets scared and makes an abrupt movement. The mother collapses and faints. The women in the colorful clothing are all over her, calling for the men, who then come and carry her inside.
Out in the courtyard, the peace settles again. The baby, still lying in the cart, is taken care of by new hands.
I have seen my first mother with her newborn baby in a foreign country.
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List of abbreviations
ANC Ante Natal Care
ANM Auxiliary Nurse Midwife
ASHA Accredited Social Health Activist EmOC Emergency Obstetric Care JSY Janani Suraksha Yojana1 MDG Millennium Development Goal
MMR Maternal Mortality Ratio MPHC Methodist Public Health Center NIPI Norway India Partnership Initiative NRHM National Rural Health Mission PHC Primary Health Center
PNC Post Natal Care
SBA Skilled Birth Attendant
Sida Swedish International Development Cooperation Agency TBA Traditional Birth Attendant
UNICEF United Nations’ Children’s Fund UNFPA United Nations Population Fund U.P. Uttar Pradesh
WHO World Health Organization
1 Hindi for “pregnant women safety scheme”. Name of a program giving incentives for deliveries in governmental institutions.
1
1.0 Introduction
Globally more than half a million women die every year from pregnancy or child-birth-related complications. The majority of these deaths happen in low income countries, and most of them are avoidable. (1) India contributes to 22% of the global burden of maternal mortality.
With a population of 1.15 billion and a maternal mortality ratio (MMR) at 301, India is the country counting for the highest number of deaths alone. (2)
The United Nations Millennium Declaration was signed in year 2000. From this declaration the eight Millennium Development Goals (MDGs) were formulated, and the world’s leaders stated their commitments. (3) Improvement of maternal health is addressed with two targets in goal number five, MDG5: target one is to reduce the maternal mortality ratio by three quarters, and target two is to achieve universal access to reproductive health. The time span for the reduction is 1990-2015. Numbers from 1997-2003 show that maternal mortality in India has declined. A decline from 504 to 301 deaths per 100.000 live births indicates that while the country is developing in the right direction, it is unlikely to meet MDG5. (2)
The access to skilled care during birth is considered a major factor for safe motherhood. To deliver in an institution is also considered crucial, both for ensuring the skilled attendance and for needed equipment and medicines. (4) Research from the rural parts of India shows that more than 65% of deliveries occur at home. (5) The country’s health care system is characterized by huge inequalities, and there are thorough differences both between rich and poor and between life in urban and rural areas. India’s economy is rapidly growing, and the resultant growth in private health services contributes to maintain, or even enlarge, the differences; access to health care is a varying good.
There have been a series of plans and projects to improve the situation through the history.
Since India gained its independence in 1947, numerous programs have been introduced and implemented to regulate and improve access to care. (6) One policy instrument that has been used in the poorest parts of the population is payment of incentives. Incentive-based services mean that a person gets cash or other payments to use certain services. During the last decade women living below the poverty level have been offered incentives for giving childbirth in governmental facilities in some Indian states. With the launching of the extensive National Rural Health Mission (NRHM) in 2005, the Indian government started a program giving incentives to all women for institutional deliveries, regardless of their financial situation. This
2
program is named Janani Suraksha Yojana (JSY) and is, by promoting institutional deliveries, considered one of the main components to reduce maternal and child mortality. (7) Norway supports the NRHM with money and technical assistance through the Norway India Partnership Initiative (NIPI). This was initially a collaboration to meet MDG4, but later MDG 5 has also been included in the program. (8;9)
NRHM and JSY are based on medical guidelines developed in accordance with international standards, with considering focus on the availability of skilled birth attendance and emergency obstetric care as key factors for reducing MMR. How implementations will work in the specific contexts is still unknown, and one can ask whether local resources and needs have been taken into consideration in the planning process. The number of institutional deliveries has increased considerably after the JSY. An assessment based on statistics from five states show that 54.9% of the deliveries in 2008 took place in an institution, which was an increase from 23.5% in 2006. (10) Still, research shows that previously there have been several reasons for the women to deliver at home, regarding psychosocial, cultural and traditional conditions. (5) This gives reason to believe that the women’s experiences after the changes toward institutional deliveries will represent an interesting and important perspective to explore.
This study aimed to increase the knowledge about the women’s experiences with the recent change from home births to institutional deliveries in the Hathras District in the state Uttar Pradesh in north India. By interviewing both women who had recently given child birth in a governmental institution and health officials working at different levels in the programs, the target was to broaden the understanding of the different perspectives in the change. By the researcher’s attendance at an International midwife conference in India, the data was also triangulated by adding learning and understandings from the midwives’ perspective to the discussion.
3
1.1 Background
1.1.1 Demographic profile
The Republic of India is by area the biggest country in South-Asia and the seventh biggest country in the world. The country borders
Pakistan, China, Nepal, Burma, Bangladesh and Bhutan, and with a long coastline it is also bounded by the Indian Ocean, the Arabian Sea and the Bay of Bengal. The population counts for 1.15 billion people; this makes it the second- most populated country in the world. (11) India gained independence from the British in 1947, and is today the world’s most populated democracy. The country consists of 28 states and seven union territories, with New Delhi as the capital. India has one of the fastest growing economies in the world, and the GNP in 2009 was 3827 US
dollar per capita. (12) There are huge disparities in income, and despite the rising economy poverty and illiteracy are still widespread. The difference between life in urban and rural areas is large. While the population in the cities continues to increase rapidly, more than 70% of the people still live in rural areas.
India’s major religion is Hinduism, with 82 % of the people being Hindus. Other big religions are Islam (13%), Christianity (3%), Sikhism (2%) and Buddhism (1%). (13) The most common language is Hindi, although there are numerous languages spoken in the country.
The caste-system was officially abolished when the Constitution of India came into force in 1950. Still segregation and suppression of people from the lower castes, scheduled tribes and other minority groups exist, in spite of different political attempt to legislate equal rights for all. (14)
India is the home of numerous cultures, and this makes it a country so diverse it appears more as a continent than a country. Since this study mainly investigates life and health in one specific state, Uttar Pradesh, the more detailed demography of this state is provided.
Map of India (7)
4 Uttar Pradesh
Uttar Pradesh (U.P.) is India’s fourth largest state. U.P. is located in the mid-north of the Indian continent, where it borders to Nepal in the north, Himachal Pradesh in the north-west, Haryana in the west, Rajasthan in the south-west, Madhya Pradesh in the south and Bihar in the east. U.P has a population of 166.20 million people. It is the most populous state in India, and it is also the state with the highest population growth rate. U.P. holds 71 districts, 813 blocks and 107.452 villages. (15) The name Uttar Pradesh means ”the north state”. It holds a broad spectrum of populations from different parts of India, which makes it a compound of different cultures and religions. Of the people in U.P., 74.7% live in rural areas with very limited facilities:
Percentage of households that Rural U.P India Live in a house of solid construction 12.2 46
Have electricity 28.3 68
Have access to a toilet facility 16 45
Use piped drinking water 2.0 24.5
Numbers from NFHS-3. (13)
In the group of women of the age 15-44, 63.6% are non-literate (16) and 44.3% of women have experienced spousal violence. The sex ratio is 898 girls per 1000 boys. (13) Of the households, 11.7% have a motorized vehicle. Regular media exposure (TV, radio or newspaper at least once a week) is reported to be 44% for women and 72% for men. (13) In 2008, 47.5% of the deliveries in U.P. took place in an institution. This was an increase from 20.6% in 2006. (10)
1.1.2 Maternal mortality in India
Maternal mortality in India is presented with current numbers varying from 254 to 301.(1;2;15) With a high percentage of the women delivering at home and not receiving any ante natal care, a correct number of complications or mortality is difficult to measure.
Irrespective of confusing numbers and differences in the baseline, the sources agree that progress has been made; MMR in India is declining. Maternal morbidity and mortality also differs from state to state. In the state of U.P. MMR has declined from 517 to 440 in the period 2003- 2006, still leaving the state with a MMR higher than the national average. (15)
5 Causes of death
The most frequent causes of maternal deaths are severe bleeding (25%), infections (15%), eclampsia and hypertension-related diseases (12%), obstructed labour (8%) and unsafe abortions (13%). In addition come other direct causes (8%) and indirect causes (20%). (1) The registered mortality is suggested to be only a “tip of the iceberg”, with 20-30 women suffering severe morbidity for every death. (1) Difficult labour is also recognized as a major cause of infant mortality. Like the maternal mortality, India’s infant mortality is declining. In 2006 the measured number was 57, a reduction from 80 in 1991. (17)
Maternal care: A brief history
The organized work for mother and child health in India dates back to the beginning of the previous century, where rural midwives or Traditional Birth Attendants (TBAs) were trained to conduct safe deliveries. From 1918, Midwifery Supervisors were trained at the Lady Reading Health School in Delhi, and from 1931, the expanding work for mother and child health was coordinated under the Indian Red Cross Society. By this time some of the states also established agencies for maternal welfare, but the work progressed at a slow pace. From 1955 the government started to integrate the mother and child health in the general health services, and international agents, such as WHO and UNICEF, increased assistance to the country. (18)
The first Indian National Health Policy was framed in 1983. The target of this policy was to achieve “health for all” by the year 2000, where a central component in this work was the arrangement of primary health care services and the provision of primary health centers. (17) Home deliveries and Traditional Birth Attendants (TBAs)
Until recent times, the traditional way of giving child birth in the rural parts of India has been to deliver at home. Here the women have been assisted by female relatives, by a TBA or by an Auxiliary Nurse Midwife (ANM). (5)
A TBA, also called dai2
2 Dai is the Hindi expression for birth attendant, and also the expression used by the informants when talking about a TBA.
, is a person who assists a mother during childbirth and who acquires her skills by delivering babies herself or through apprenticeship to other TBAs. (4) The expression TBA is an umbrella term including women with varying practices, according to local and personal differences. They are often respected in their community for their skills and knowledge, and they tend to be older, non-literate women. (19;20) Because such a high
6
number of women traditionally have been assisted by TBAs at delivery, large efforts has been made to improve their skills by organized training. From the 70’s WHO and the international society recommended and funded training programs, in India as well as in other low income countries. The target was to train the TBAs in basic skills for child delivery. From the beginning of the 90’s persistently high
MMR and poor documentation on the efficacy of the training led to an end to the programs. (19) In current plans and strategies TBAs are no longer considered effective resources in combating maternal mortality. Nevertheless, in some rural areas the major percentage of women still delivers at home without a skilled attendant. (5)
Institutional deliveries and Skilled Birth Attendants (SBAs)
Current strategies for reducing MMR in low income settings are now based on encouraging institutional deliveries with attendance of a Skilled Birth Attendant (SBA) and availability of Emergency Obstetric Care (EmOC). The term EmOC refers to the services of treatment for complications during pregnancy and child birth. (21) An SBA is defined by the WHO as a person with midwifery skills (for example doctor, midwife or nurse) who has been trained to proficiency in the skills necessary to manage normal deliveries and diagnose, manage or refer obstetric complications. (22) Thus, aiming at improving safe deliveries with these two
components, the new focus is now to encourage women to come to an institution for child delivery.
In India, governmental services for providing delivery care have gone through an extensive change after the implementation of the National Rural Health Mission program started in 2005. Significant initiatives under this program include upgrading of facilities, incentives for institutional births and introduction of the new worker Accredited Social Health Activist (ASHA). Guidelines for the program are given from the central government, but implementation is delegated to the government of states. This causes services and standards of care to differ to some extent, depending on the situation in the individual state.
Re-training of TBAs in Hathras District
7 Coverage and training of midwives
Like most of India’s rural areas, the rural parts of Uttar Pradesh have a vast unmet need for health personnel. Health indicators calculate a need for 7295 nurse/midwifes in the state, and the number of positions currently occupied is less than half, 3340. (15) With the clear exception of male doctors at the PHCs, shortage of all types of health personnel is reported.
Both health infrastructure and utilization of the services are connected with other types of demographic factors, as availability and possibilities are highly dependent on local context.
Today there are two types of midwife education in India. (23) The trained nurse midwife has a three-year nursing program containing six months of midwifery. This gives a degree and registration as both a nurse and a midwife. The Auxiliary Nurse Midwife (ANM) is a multipurpose female health worker with 18 months training, six of them in midwifery. Both groups are educated to manage normal deliveries, but responsibilities and tasks vary a lot depending on geography. The distribution between the two groups is also geographically skewed, with 90% of the trained nurse midwives working in urban areas, and 90% of the AMNs working in the rural areas. (23) The ANM has also traditionally attended home deliveries in rural areas. (19)
The organization Society of Midwives, India (SOMI) was launched and registered in 2000.
This union for midwives works tightly with the nursing academies to improve midwifery services and professional integrity. Headquarter for SOMI is located in Hyderabad, and national conferences are arranged annually. (23)
1.1.3. The National Rural Health Mission
The National Rural Health Mission (NRHM) was launched by the Indian government in 2005.
The program is an extensive initiative for reforming the access to basic health care in rural areas, especially focusing on women and children. Major focus areas are reproductive health, sanitation, hygiene, nutrition and safe drinking water. Eighteen high focus states with poor health services are given priority, among them Uttar Pradesh. The initiative seeks to make services equitable, affordable, accountable and effective in order to achieve better the health conditions and standards of living in the rural areas. (7)
The government has a policy of transparency in all segments of the program, and all reports and evaluations are available online. Implementation of the program is decentralized to state- and district management. The NRHM is planned to run till 2012.
8
The two most significant policies affecting women giving birth are the introduction of the Janani Suraksha Yojana (JSY) scheme and the creation of Accredited Social Health Activists (ASHAs). (7)
Janani Suraksha Yojana (JSY)
Janani Suraksha Yojana is Hindi for ”pregnant women safety scheme”. In this program women or families are compensated for delivering in a governmental institution, receiving a one-time payment of 1400 Indian rupees (= 186 NOK). (7) The objective is compound, partly to make the mother deliver under safe conditions and with skilled attendance, and partly to get the children enlisted for vaccinations. The scheme is a modification of an earlier system, where incentives for institutional deliveries were given only to women below the poverty line.
Now all women can receive a check-payment for delivering in a governmental institution, regardless of factors such as financial situation, number of children or geographic area. (24) The Accredited Social Health Activist (ASHA)
The ASHA is a female social health worker, selected and trained to work in the community.
She functions as a connection to public health services, and her payment is based on incentives for performance. She has a number of tasks, among them to follow the women to the institution for delivery and to follow up with vaccination programs in the community. The plan in the villages is to have one ASHA per 1000 population. (25) Women recruited to be trained as ASHA should preferably have attended school up till class eight. The training consists initially of 23 days in five episodes, and further training will be available for development of knowledge and skills.
1.1.4. The Norway India Partnership Initiative
The Norway India Partnership Initiative (NIPI) was initiated by the two countries’ Prime Ministers, Manmohan Singh and Jens Stoltenberg, in 2005. In 2006 the letter of intent was signed, and a five year plan was developed. (8) The objective was to give administrative and financial support to implementation of the mother and child health programs under the NRHM. NIPI has a budget of 500 million NOK for the five-year period. The main target from the start was to meet the MDG4, and later MDG5 was also included in the formal target. NIPI also aims to identify and develop good solutions and strategies for working with mother and child health both locally and on a larger scale, with possibilities for transferring knowledge to other countries. In 2006 and 2007 agreements were made with WHO, UNICEF and UNOPS for funding and organization. (8)
9 NIPI in Uttar Pradesh
Five states were initially selected for the NIPI work, namely Bihar, Madhya Pradesh, Rajasthan, Orissa and Uttar Pradesh. These five states were identified because of high population numbers and high IMR and MMR. In the other four states the work is under progress, but by the beginning of 2010, the work in U.P. has still not commenced.
When U.P. was chosen for this project it was still expected that NIPI would start working in the state; but by the time the field work in Hathras started, the program launch was shelved for the indefinite future. Even though U.P. is no longer considered a “NIPI-state”, their work is still relevant for this project and are therefore maintained as part of the framework: the challenges foreign agents meet in the U.P., NIPI’s policies and not at least the idea of NIPI’s new worker Yashoda are all relevant topics when discussing different perspectives on the changes after NRHM and JSY in U.P.
The Yashoda
One practical implementation from the work of NIPI is the introduction of the new health worker Yashoda. The Yashoda is a trained female health worker working in the hospital. Her main tasks are to give the mother support during delivery, promote early and exclusively breastfeeding and to encourage the mothers to stay at the hospital for 48 hours after time of delivery. The name Yashoda is taken from the name of the foster mother of Krishna, a main Hindi god. (7;26) The introduction of this worker is a strategy for encouraging the women to come to the governmental hospital for child delivery, and not at least to make them stay in the institution afterwards. The support from the Yashoda represents something new in the Indian hospital system, where care and support traditionally has been given mainly by the family members. The implementation of Yashoda is a strategy for giving the women another experience of the care in the facility, and through this also creating a possibility for teaching and informing the mothers about important health issues.
10
2.0 Literature Review
A review of literature was done during the planning phase of the study. Knowledge from relevant literature and research articles were presented at IASAM (UiO) in April 2009.
During the field work new literature was added. For up-date, a new search was done in April 2010 with the same key words.
2.1 Literature search
The main search engines for the review were PubMed and Google Scholar. Further, the WHO, UN and NRHM websites, the curriculum of the master course, resource persons and the snowball method from articles already found were used. Key words for searching were delivery(ies), institutions, incentives, obstetric care, maternal mortality, traditional birth attendants, skilled birth attendants, emergency obstetric care, NRHM, JSY, ASHA, Yashoda and India, used in different combinations.
Theories and literature on methodology will be presented and used in the chapter on methodology.
2.2 Current knowledge
The Indian MMR is described as declining by both research and statistical sources.
(5;7;13;17;24) Review- and research articles shows that different strategies are proposed to reduce the MMR, both in rural India and in other low-income settings. (27-30) Two main topics are identified to affect the outcomes; first having a Skilled Birth Attendant (SBA) for delivery and, second, giving birth at a facility with capacity for Emergency Obstetric Care (EmOC). (4) Even though promoting availability of these two resources is now considered the main procedure for combating MMR, several other factors are suggested to influence the impact of interventions. These factors are the economic, political, cultural, religious, psycho- social, strategic, administrative, managerial and historical aspects of the setting.
(2;5;29;31;32) Lahariya (24) calls attention to the need for improvement in the facilities both regarding quality and capacity, to be able to accommodate the increasing number of women using the facilities. Trained staff is another factor identified to be important for the effect of EmOC. (29) Research from other low-income countries presents that institutional deliveries and need for EmOC can involve heavy expenses for the family and result in financial problems. (33)
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The importance of a continuum of care with continuity during pregnancy, childbirth and the post natal period is emphasized; significantly, the focus on ante natal care is pointed out as a prerequisite for a successful program. (2;5;24)
Context and local differences are identified as key elements by Penn-Kekana, (34) showing that the strategy for implementation must be emphasized in all change involving human interactions.
Parts of the research, especially on the effect of the training of the TBAs, are conflicting and limited. (19) Nevertheless, results from studies on the TBAs coincide in their findings on several points. The effect of training is difficult to measure, both because most of the TBAs have already received some training when the intervention starts, and because of the combination with other programs. Another common finding is that more research is needed before reaching definitive conclusions. Qualitative studies also show that the role and the practice of the TBAs vary greatly from place to place, and thus it is difficult to generalize.
(19;20)
Statistics from NRHM show that hospital deliveries in Uttar Pradesh increased from 11.2% to 47.5% in the period 1992- 2008. (7) It seems that NRHM and the introduction of JSY has been a success so far. Still, other sides of the programs are viewed critically, from both government and researchers. (6;7)
Determinants for the women’s choices are elaborated in detail in different studies. (2;5;31) Matthews, Ramakrishna, Mahendra, Kilaru and Ganapathy (5) found that 89% of the women planned to deliver at home because they, among other factors, wanted to give birth in the cultural and traditional setting of a home delivery. Support from the family was another motivator. From this there is reason to question whether these women will experience a loss regarding culture, tradition and not least the needed support by having an institutional delivery. Experience of sufficient support, meaningfulness and relaxation are known to play major roles for women giving birth, for both psychological mechanisms and progress during the stages of labor. (35) The implementing of the Yashoda in the hospital is an attempt to meet the mother’s needs during and after birth. (7;26)
Srivastava, Kansal, Tiwari, Piang, Chand and Nandan (36) shows that utilization of the governmental services in U.P. is higher among the population from low castes and low socio- economic backgrounds. They also show that a very low percentage utilize all the important
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elements of the care. The authors also investigated the satisfaction among the users, with results indicating that 16.3% was not satisfied with the services.
2.3 Identified gaps in the knowledge
Although reports and assessments of the NRHM and JSY exist, (7) essential research on both process and effect of the incentive-based deliveries is still missing. This raises a question of whether a quantitative study should be carried out instead or in addition. First, the size of the change is much too extensive to be quantified in a master’s degree thesis. Second, there is also need for qualitative research in this field. Knowledge about the experiences of the women and further understanding of the gap between these experiences and the initial intentions can give important information when evaluating and making new steps in the programs.
Deeper knowledge about the user’s thoughts and experiences after an intervention can broaden the understanding of the change and thus contribute a new and important aspect. The aim is to add meaning to the statistics, and to give ideas for further work and planning. After a change like this, it is also an ethical question whether it should be considered important and obvious to raise the voice of the people affected. When plans are made far away from the area of implementation, it is essential to measure how it is received. (32)
In a larger picture, Fretheim and Hviding point out that strong evidence on the gain of facility-based deliveries is lacking. (37) The same authors also claim that no rigorous study has been done to demonstrate that delivering with a skilled birth attendant will reduce mortality on an individual level. They conclude, on the other hand, that such a study may not be ethically acceptable because of the logical arguments in the favor of the facility-based deliveries and the skilled birth attendants.
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3.0 Study rationale
The NRHM has brought changes to the Indian health care system. Statistics show that the number of institutional deliveries has increased, (10) but not much is done to investigate the impact or possible consequences seen from the women’s perspective. Recent assessments (7) and studies done on quality of care (38) indicate a gap between programmers’ intentions and experiences of the users. This study aims to explore this gap. Its main objective is to explore the women’s experiences after the recent change, and further to investigate the gap between these experiences and intentions and expectations of policy makers and health care professionals.
When developing strategies for rural India, guidelines are based on broader ideas developed in the international community. Research has shown that to carry out an action in a successful way requires knowledge about realistic possibilities and resources in the field, and adjustments for local differences. (34) Every change may bring expected and unexpected consequences, which again will influence and act on new terms. Hence, as context specific matters may play a role for implementation of new programs, this study aims to broaden the understanding around the recent change from home births toward incentive-based institutional deliveries in Hathras District, U.P.
3.1 Research questions
3.1.1 Interviews with women who had recently given child birth
Women who had recently given birth were interviewed in their homes after discharge from the facility. Qualitative data was gathered from 22 interview-settings, based on a question guide. (Appendix no.1)
Research questions for investigating the women’s experiences were formulated as
1. How do the women utilize the local interventions from NRHM, which parts of it do they use and why?
2. How do incentives for institutional delivery affect
• Their view on pregnancy and childbirth as normal or medical happenings?
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• Their understanding of maternal mortality and morbidity?
• Their view on cultural and traditional perspectives in the intra partum period?
• The role and function of the family members?
• Their relation to the health care system?
• Their self-image?
• The empowerment of the women?
3.1.2 Interviews with health officials
As representatives from the policy makers, five health officials were interviewed. These five informants were holding positions at different levels of the programs. The interviews were based on a question guide. (Appendix no.2)
Research questions for the health officials were 1. What are the intentions of NRHM/JSY?
2. How are the programs implemented?
3. What are special challenges?
4. How do they believe NRHM/JSY affect the women in the rural areas (regarding themes listed above)?
3.1.3 Perspectives from the Asia Pacific Midwives’ Conference
The researcher’s attendance at the Asia Pacific Midwives’ Conference (APMC) was an attempt to increase the knowledge on background and ideas that governs work and research on maternal health in India. Information was collected through attendance at selected presentations complemented by discussions with speakers and participants.
Research questions from the APMC were
1. What professional ideas and views influence the planning and implementation of the NRHM/JSY?
2. What is involved in the theoretical perspective of childbirth and midwifery in India?
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3. What are the midwives’ concerns regarding the change towards institutional deliveries in the rural areas?
3.2 Limitations
India is a country of vast variety. The women in this study were interviewed in one geographical area, namely in Hathras District in Uttar Pradesh. Due to this, and also due to the qualitative nature of methods used, findings from this study cannot be generalized.
Findings can to some extent be transferred to other similar settings in India and can be of interest when investigating the same topics in similar contexts. Still, cultural, administrative and political differences will influence both process and outcome of implementations of a program like the NRHM, and thus influence the findings.
The private market for health services in India is rapidly increasing. As this study aims to investigate changes after the introduction of a specific governmental program, the private supply of health services are not taken into consideration other than where it is natural and essential for the context.
The changes towards institutional deliveries are influenced by numerous aspects of changes in Indian society. For this project, the researcher has chosen which parts to emphasize based on the research questions and on the topics relevant for the findings from Hathras. Other topics of current interest like caste, poverty and gender will not be conceptualized or discussed unless natural in the context.
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4.0 Methodology and research design
A study’s method is decided by its purpose. As this project’s purpose was to get an in-depth understanding of peoples’ experiences, qualitative methods were the most appropriate. In qualitative research the process is considered as important as the outcome, and the researcher’s role is a tool that must be defined and described. (39) Patton (39) suggests the use of “I” in qualitative research, to communicate the inquirer’s self-aware role in the inquiry.
The researcher’s use of “I” can state and support the subjectivity which follows the nature of a qualitative study. It also helps clarifying questions about roles and perceptions when the author’s eyes are clearly presented as one of the tools.
Different theories and methods used for the different stages will be elaborated in this chapter.
This presents a methodological foundation for the project and shows how it was planned and carried out. Major changes along the way will be elaborated in the discussion of methodology.
The study was based on data from semi-structured interviews and participation at a conference, with opportunistic observations and informal conversations also being sources for background understanding. Statistics already existing gave a foundation for the qualitative approach in the field, and was a part of the larger setting in which the study was conducted.
4.1. Theoretical framework
A theoretical framework is the set of theories and ideas used for a study. (40) This framework will decide how the study is planned, how data are gathered, transcribed and analyzed, and at last which results the researcher presents when the work is completed. The framework is first of all an implement for the working process. It helps the researcher to keep coherence through the different stages in the process, giving a theoretical basis for sorting out and identifying relevant data, as well as for analyzing and writing. (40)
Theories on qualitative inquiries
This study was done with a holistic and inductive approach. A holistic perspective is seeing the person or the phenomenon as a whole, rather than as a composition of its parts. In this lies a focus on the complex interdependencies and dynamics making the synthesis something more than just the sum of its parts. (39) A holistic view was intended through all stages of the project, from planning, approaching the field, gathering data, analyzing and presenting the work. An inductive approach means that the understanding will grow from the individual to
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the collective level. The learning comes through investigating specific cases and, from this, learning something about the general. This method is also referred to as “bottom-up”, where we get higher understanding about a topic by using knowledge gained from the specific and individual level. (40) This approach contains a paradox: To be able to understand the informants’ specific experiences, the researcher has to put aside her own understandings, which requires identifying her own theoretical framework and how this will influence the interpretation of the material. At the same time we know that this is not entirely possible. The acknowledgement of this is essential for understanding what the material really tells us. One way of facing this challenge is to use a phenomenological approach to the informants and the material.
Phenomenology was first introduced as a philosophical tradition by Edmund H. Husserl (1859-1938) as the study of how things appear to us and how humans describe their experiences through their own perceptions. As an inspiration for exploratory research it can be used as an attempt to grasp the informants’ experiences and views in a special field. (39) The researcher must then bracket her own presumptions to be open for the view of the other.
This requires knowledge and reflections on how our own perceptions will influence the data.
Reflexivity, the ongoing examination on what we know and how we know it, is a key concept in this process and is elaborated as a separate point.
Holism and phenomenology form a foundation for exploring phenomena as they occur; the phenomena are seen partly as they are, without interpreting them into a previously known context, but also partly as components in a larger synthesis. Persons’ searching for organizing the experiences in meaningful synthesis can be illustrative when trying to understand their experiences. Kvale and Brinkmann (41) refers to the term “Life World” as the interwee’s lived everyday world, which can be seen as the informants’ platform for their experiences.
Analysis of the material was done in four steps after two approaches described by Patton 2002 (39) and Malterud 2006 (40). Patton refers to Moustaka’s phenomenological model, where the process of analysis is divided in four steps: epoche, phenomenological reduction, imaginative variation and synthesis of texture and structure. Epoche is a Greek word meaning to refrain from judgment. This is the start, where the researcher stays away from her everyday way of perceiving things. Here she looks inside to become aware of personal involvement and personal bias, to identify and clarify where this influences the data. In the next step, the phenomenological reduction, the researcher “brackets” what was identified in the first step,
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trying to see the data in its pure and original form, without the perception of the researcher (herself). The next step is imaginative variation, where the data is “horizonalized”, which means that all data has equal weight. From this it is gathered in meaningful clusters. In the last step, the synthesis of texture and structure, data is integrated and structured to present a synthesis of the meaning and essence of the experiences. (39)
Malterud (40), referring to Giorgi’s phenomenological analysis, presents a model containing most of the same theory as Patton, but with a small variation: Malterud starts the analyzing process with getting an overview, with reading all the transcribed data without marking the details, to get a picture of what the data contains as a whole. Through this stage she also emphasizes the importance of identifying our preconceptions and personal involvements to eliminate bias. To start out with getting an overview can result in two things. Either the researcher gets an overview for the rest of the work, a start for the analysis process and a knob on which to hang the further understanding. The other possible result is to start out with getting all preconceptions and prejudices confirmed right from the start, which will make it very difficult to work with an open mind. I believed that with consciousness around this potential problem I would benefit from the advantages of getting an overview.
Professional standpoint
Current knowledge and theories in the subject were also a part of the theoretical framework, and this again was interpreted through my personal and professional standpoint. The theories of Skilled Birth Attendants (SBA) and Emergency Obstetric Care (EmOC) are considered key factors for reducing the maternal mortality globally, (4) and they were chosen to be a part of the frame for this study due to their position in current research. However, with research and evidence-based medicine being subject to rapid and constant change, the theories must also be viewed critically. My personal experience, as a midwife with special interest in natural birth, has influenced the material in different ways. This will be elaborated in the chapter on reflexivity.
4.2 Study site
The interviews with the women who had newly delivered were carried out in the Hathras District, India. Planning, observation and informal conversations were done in the town of Mursan and the nearby cities of Hathras, Mathura and Aligarh, and also through attendance at clinics and camps in the district’s villages by the Methodist Public Health Center (MPHC).
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Women were recruited from the Primary Health Center (PHC) in Mursan. This facility was one of five PHCs in the Hathras District. As a governmental institution it offered delivery services around the clock with Skilled Birth Attendance and Emergency Obstetric Care. A doctor was present till 2 pm, after which time deliveries were conducted by midwives. For advanced obstetric care the woman must be referred to the district hospital in Hathras. When referred to in this paper, this PHC in Mursan will be mentioned in terms as the primary health center (PHC), the institution, the facility and the hospital.
The health officials included in the study were interviewed in different geographical areas, one in the Hathras District and four in New Delhi.
The Asia Pacific Midwives Conference (APMC) was held in Hyderabad, the capital city of the southern Indian state of Andhra Pradesh.
4.3 Study population
4.3.1 Women who had recently given birth
To get information about the women’s experiences after the changes toward institutional deliveries, women who had recently given birth at the PHC in Mursan were recruited as informants. The women were living in Mursan or the surrounding villages. The majority of them were housewives and, due to local custom, many of them originated from other areas and had moved into the in-laws after marriage. The households involved, without exceptions, extended families, with the grandparent-generation living together with their sons and daughters-in-law, any great grandparents still alive, unmarried daughters and sometimes also daughters who had become widows at a young age. Female family members participated in the interviews to varying degrees.
4.3.2 Health officials
To get an understanding from the authorities and policy-makers, five health officials from different levels were interviewed for this study. One of them was the chief doctor at one of the PHCs in the Hathras District, responsible for implementation of the NRHM services at the very local level. The second and third were from the Ministry of Health and Family Welfare in Delhi. Of these, one of them was a consultant holding special competence and experience in the planning and implementation of JSY for the central government. The other was a consultant with shorter time of service in the ministry, but with long experience from work with reproductive health in rural areas. The fourth and fifth were representatives from the
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Norway India Partnership Initiative (NIPI)’s central office in New Delhi. To possibly identify different views within NIPI, one Norwegian and one Indian representative were selected for the study. Of the five persons, two were females and three were males.
4.3.3 The Asia Pacific Midwives’ Conference
The Asia Pacific Midwives’ Conference (APMC) was organized by the Society of Midwives, India (SOMI). The conference had more than 500 participants, and countries from all continents were represented. Here midwives, gynecologists and other stakeholders shared their views through speeches, lectures, seminars/discussions and workshops. The objective of the conference, from the organizers’ perspective, was presented in three parts:
• Exchange information and skills for providing high quality services to women, babies and families.
• Learn from experiences of associations in shaping and strengthening midwifery profession in different countries
• Share a vision and formulate actions for equitable access to services for women and their babies.
4.4 Sampling
Sampling of a specific target group to give an in-depth understanding of a special case or phenomenon is called purposeful sampling. In a qualitative study the aim is not to get a result sufficient to generalize, but to get in-depth information about special cases. (39)
Women who had recently delivered in a governmental institution
The main target was women who had given birth at a governmental institution for incentives, and who also had delivered at home previously, with different types of assistance. Twenty- four women were initially recruited for the study. Of these, 13 had a history of earlier home delivery. Additionally 11 women who had not experienced a previous home-delivery were interviewed: three of these gave birth for the first time, while eight had previously delivered in an institution. Participants had to be 18 years or older to be included in the study.
The women were recruited through records from the PHC (22 women) and through the snowball method (two women). They were visited in their homes after discharge from the facility, and they were given an explanation about the study and invited to participate. They were also given the option that we could come back for the interview another day, irrespective
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of sampling method. All 24 women asked agreed to participate and to do the interview right away.
Of the 24 women (and their female relatives) who were interviewed, two of them were excluded from the study after the interview because of former child delivery at the MPHC.
This was an exclusion criterion for participating in the study, due to risk of biasing the information because of the team’s affiliation with the MPHC.
Inclusion of female relatives
Initially the aim was to conduct private interviews with the women who had recently
delivered. From the first interviews, however, we saw that in spite of our attempt to talk with the mothers in privacy, the female relatives remained present for the conversation. The cultural norm was such that the mother-in-law was the decision maker in subjects regarding women’s health. It was unnatural and difficult to insist on talking with the new mother in privacy in the family’s home; it would put the mother in an uncomfortable and possibly dangerous position. It could also affect the data; the women would act reserved if they were scared that the relatives would listen outside. If the interviews were conducted another place, where the woman could be alone, this situation would be different and thus probably give richer information. On the other hand, it was common among the mothers that they did not go out much, they were housewives and they stayed close to the home, so recruitment for this would be a challenge. After recent child delivery they were also particularly vulnerable, and it was considered important to interview them a place they were comfortable. The subject of the women being a vulnerable group is elaborated under the ethical considerations. The initial obstacle with the female relatives not willing to leave the conversation was utilized as a resource to get extended information. When they also were invited to participate in the interview, the conversations were more easy and natural. Especially supplements from the mother in-laws gave information from another generation and another time, which gives the current changes and experiences a larger perspective.
Health officials
Health officials were sampled purposefully to represent views from authorities and were selected based on their positions. To collect different perspectives within the group of officials, informants with different positions were recruited.
22 Attendance at the Asia Pacific Midwife Conference
Attendance at the APMC gave access to a midwives’ perspective on the subject. The researcher selected relevant presentations and approached speakers and participants for discussions and informal conversations.
4.5 Timeframe
This study was conducted within the frames of the Master of Philosophy degree in International Community Health at the University of Oslo (UiO). In April 2009 an abstract was submitted followed by a literature presentation at the University. Research protocol was submitted to the UiO May 25, 2009. The project was approved by the Regional Ethical Committee (REK) in Norway in June 2009.
The fieldwork in India took place from August 31- December 09, 2009. While waiting for local ethical clearance observation was done, and then the study was commenced after clearance was received on October 14, 2009. Interviews were conducted during the period October 20- December 04, 2009.
4.6 Data collection strategies
4.6.1 Observation and informal conversations
The first six weeks of field work were used for exploring the new culture. This was done through informal conversations and opportunistic observation3
Informal conversations were also conducted at the Ministry of Health and Family Welfare with employees from different departments.
, where information was collected and written down in a diary. My contacts in the community and at the MPHC were of great importance to gain access to the society. I learned about everyday life, culture and health care by spending time in the clinic at their health center and by going out on health camps in the villages. Also guided walks gave an introduction to the place seen through the locals’ eyes. Further, visits to governmental hospitals allowed informal conversations with women giving birth, midwives, doctors and assistants.
3 Observation in this relation refers to the everyday use of the word, therefore the term “opportunistic”. It must not be mistaken for observation as ethnographic method of qualitative inquiry.
23 4.6.2 Semi-structured interviews
The word interview literally means ”inter view”, where the interaction between the interviewer and the subject, and the knowledge constructed there, is the essence. It can also be seen as an “inter-change of views between two persons conversing about a theme of mutual interest”, where the interviewer follows up answers and asks for details and elaboration. (41) In this way the interview is not a conversation between two equal partners; the power structure occurring when the researcher has the power to control the dialogue with questions and turns can make the interview a one-way session. An interview can be seen as holding two aspects. The first is the relationship between the two parties and the second is the knowledge this relationship yields. (41)
For interviews with both mothers and health officials, the conversation was based on a question guide with open ended questions. The aim was to get information and a description of the life world of the informants, and how they saw and experienced the recent change with the JSY. Their views and experiences would include aspects of life other than just child birth, and understanding their life circumstances was important when trying to grasp their understanding of how things were related. The aim was to collect personal stories in order investigate how the informants saw their situations, and why certain issues were important to them.
All the informants were interviewed once. The interviews lasted from 15- 75 minutes. A tape recorder was used in all settings except from at the interviews at the Ministry of Health and Family Welfare.
Interviews with women
The interviews with the women were conducted in the informants’ homes. The physical setting was aimed to form a triangle, where the mother, the interpreter and the interviewer were seated so we could all see each other. Other female family members participating were taking seats around in the room, subject to limitations of space and furniture.
After clarification around participating in the interview, the conversation continued with the translator reading through the Informed Consent Form. (Appendix no.3) Possible questions around this were answered and the informant gave her consent with written signature (12 women) or thumb print (ten women).
24 Interviews with health officials
The health officials were visited in their offices. The interview with the chief doctor at the PHC was carried out partly in English and partly with a Hindi translator. The translator was one of the male assistants from the Methodist Public Health Center. The interviews at the Ministry of Health and Family Welfare were conducted in English. At the NIPI office, the interview with the Indian representative was done in English, while the interview with the Norwegian representative was done in Norwegian.
4.6.3 Other sources of data
The Asia Pacific Midwives’ Conference was a four days conference with speeches, lectures and workshops on midwifery and reproductive health. Participation at this event gave the researcher access to information from the midwives’ perspective, and to what is stirring in the specialist environment both regarding research and procedures for clinical work. The researcher participated as one of many international delegates. Learnings and impressions were taken down through hand written notes. Several of the speakers were contacted afterwards for elaboration, both at the conference and through later correspondence.
4.7 Research assistants
The work of this project made use of different types of assistants. Most of the interviews were conducted with an interpreter, and other assistants also accompanied the researcher when and where it was convenient or considered culturally appropriate.
4.7.1 Translator
Because of the lack of formal education, the English language skills of the women to be interviewed in the Hathras District were anticipated to be poor. So as the researcher had no knowledge of Hindi, the work was planned to be implemented with assistance from a local translator. The importance of using a female translator for the interviews with the women was stated from the planning of the study. It was also preferable to have a translator without connection to any of the local hospitals in order to avoid bias.
The process of finding a translator
First, a female translator was expected to be necessary for gaining access to conversations with women in privacy. I expected the cultural code would prohibit women talking with unknown men; and with me also being a stranger; I anticipated a female translator would be more appropriate. The topics for the conversation were of sensitive character, and the women
